The Quality Center's Patient Safety Organization 
January/February Newsletter 
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January/February 2018 Newsletter
PSO News
- Revisiting Color-coded Wristbands & DNR Wristband Survey
- National Patient Safety Awareness Week

PSO Safety Platform
- Look for RCA Feedback in 2018
- Data Quality - Clear the Red!

Feedback & Learning
- Handoffs & Transitions of Care 

Legal Update
- Court cases in Florida and Kentucky challenge and clarify PSWP protections.

Upcoming Events At-A-Glance

2/6 - PSO Member Virtual Huddle:  2018 Pt Safety Week Activities Planning
2/27 - Webinar: Concentrated Insulin

3/8 - Webinar: Handoffs and Transitions

4/5 - Webinar: Feature of Pt Safety Awareness Activities 
4/26 - Safe Table: Patient- Staff Violence - RTP, NC

6/14 - RCA2 - RTP, NC 

8/16 - Safe Table: Culture of Respect - RTP, NC

9/TBD - Webinar: Standardizing Safety Practices: Beyond Checklists

10/15-16 - Quality and Pt. Safety Symposium - Chapel Hill, NC
10/TBD - Webinar: Learning Environment & Good Catches

11/TBD - Webinar: Socializing Measures of Harm - NextPlane Measures Program


PSO News

Revisiting Color-coded Wristbands
DNR Wristband Survey

Are hospitals still using purple wristbands? Are there other best-practices for identifying code wishes? In 2008, the American Hospital Association published an advisory for hospitals using colored wristband as alerts with recommendations to standardize the color scheme. In 2009, the North Carolina Quality Center spearheaded a voluntary initiative for NC hospitals to adopt the colors proposed by AHA (red for allergies, yellow for falls, purple for DNR).
Some hospitals have gone beyond color scheme standardization and instead eliminated all color-coded wristbands. However, the convenient “alert” of a bright colored wristband may be missed by some health care providers. 

We recently received inquiry specifically about the use of the purple DNR wristbands in the inpatient hospital setting from one of our members, so we are reaching out to you for your feedback. We want to hear from you! Does your hospital use purple DNR wristbands? Please complete before February 15th. Thank you! 
Click Here to Complete our Brief DNR Wristband Survey
Don’t forget.  .  .
With the rapid onset of the new year, March has a tendency to sneak up! NPSAW provides a wonderful opportunity to highlight and publicize the great patient safety work your organization does. Planning education and unique activities requires thought and creativity. Do you have plans already? Need some fresh ideas?
Join us on February 6th @2pm for our first-ever PSO Huddle Call to share ideas for NPSAW education, activities, and events. Bring your NPSAW past successes, royal flops, and aspirations to the call! 

PSO Safety Platform

          Look for RCA Feedback in 2018

You’ve asked and we’ve listened! During 2018 you can expect to receive high level feedback on RCAs uploaded into NextPlane. Keep in mind that the quality of information submitted will impact our ability to provide useful feedback.  Please make sure to submit related RCAs once available into the NextPlane safety platform during your monthly uploads. Not only does it offer protection of these documents they  will assist with the planned reviews. Stay tuned for more information or contact Claudia Paren with questions. 
Data Quality – Clear the Red!

Just a friendly reminder, when you upload data to our safety platform, before you process the records make sure to correct any red that appears in your mapping template . Forgot how? Visit this resource.

When key pieces of information are missing, like the Event Type and Severity, it can be challenging to identify trends or to generate meaningful reports for our members.

Feedback & Learning

Hand-offs & Transitions of Care

Hand-offs of patient information represent a critical component of patient care. The impact of omitted or incorrect information can range from insignificant to tragic.
Approximately half of the events submitted to the Quality Center PSO featuring “handoff” or “hand-off” as a keyword have been coded as resulting in patient harm!
The Joint Commission published Sentinel Event Alert 58 in September 2017 addressing the inadequacies of hand-off communication. You can read more about the Joint Commission’s recommendations here
We will also be holding Safe Tables and webinars on hand-offs and transitions of care soon, continue to check our website for more information!

Joint Commission Updated RCA Template!

The Joint Commission’s 24 RCA Question template was updated in October 2017 and serves as an example of a comprehensive systematic analysis. The framework and its 24 analysis questions are intended to provide a template for analyzing an event and an aid in organizing the steps and information in a root cause analysis.
An organization can use this template to conduct a root cause analysis or even as a worksheet in preparation of submitting an analysis Access it


Court Cases in Florida and Kentucky Challenge and Clarify PSWP Protections.

States continue to interpret the intent of The Patient Safety & Quality Improvement Act of 2005. PSO relevant legal cases from Florida and Kentucky were highlighted during the Legal Update: Impact of Recent Legal Cases on Patient Safety Work Product” webinar sponsored by NextPlane Solutions in December 2017. 

For the summary details of these two cases visit here

Did you miss the webinar? Click here for the replay.
Lessons Learned from the Florida and Kentucky Cases
Although these cases occurred in states that have no peer review protections, there are some important implications to keep in mind for asserting privilege:
  1. Is your patient safety evaluation system (PSES) policy developed and approved?
  2. Does your PSES policy use the "deliberations and analysis" pathway for creating PSWP? 
  3. Information immediately becomes PSWP when collected and entered into the organization’s PSES.
  4. For states with mandatory reporting, clarify exactly what information is to be submitted. The reported information is considered non-PSWP.
  5. Plaintiff will seek to discover if you have a documented PSES and its associated policies to clarify what is considered PSWP.

Upcoming In-Person Learning Opportunities

Don't Miss Out . . . Host a  PSO Safe Table!

What is a Safe Table? A Safe Table provides a forum for NCQC PSO members to network and exchange patient safety experiences and best practices in an open, uninhibited and legally protected environment.  Safe Tables are legally protected under the Patient Safety and Quality Improvement Act of 2005 that allow health care providers to convene and have open dialogue about patient safety and quality of care issues.  All attendees are required to sign confidentiality agreements.  

Hosting is simple. We handle the external marketing and registration logistics, you assist with securing the meeting space and coordinating light lunch with us.There are no fees for participants to attend and hosting reduces travel cost for your staff.    
2018 Safe Table Topics

Health Care Technology: Frustration and Fixes- Program Flyer
This Safe Table will explore and encourage engaging discussion about health technology frustrations and fixes that impact clinical work processes and the work environment.
February 14, 2018 - Nash Health Care System. Register Here 

Handoffs & Transitions of Care
March & April - Dates and Locations TBD

Patient-Staff Violence
April 26, 2018 - NC Healthcare Association -  RTP, NC
May & June - Dates and Locations TBD

Elopement Risks
June - Date and Location TBD

Culture of Respect
August 16, 2018 - NC Healthcare Association - RTP, NC
September - Date and Location TBD

Patient Identification 
September & October - Dates and Locations TBD

Bar-Coded Medication Administration workarounds 
October & November - Dates and Locations TBD

Interested in hosting a Safe Table?
Contact Laini Jarrett at or 919-677-4123.

You can register for upcoming safe tables and other events at our QC PSO website
                           Save the Date
Root Cause Analysis and Action (RCA²)
Date: Thursday, June 14, 2018
Location: NC Healthcare Association - Cary, NC 
RCA2: Improving Root Cause Analyses and Actions to Prevent Harm is a framework for root cause analysis endorsed by the NPSF. As the name suggests, the framework puts an emphasis on action – underscoring that discovering the cause of a problem is only useful if change happens as a result. With RCA² the approach is different – and so are the outcomes. 
Come learn about the RCA2 process, tools and barriers and how it can improve your safety culture. This course will be lead by Jessica Behrhorst, MPH, CPHQ, CPHRM, System Director of Quality and Patient Safety at Ochsner Health System, a 13-hospital health care system. Jessica  has presented at NPSF conferences on her team’s experiences in implementing the RCA2 process. Registration information coming to our website soon.
                         Save the Date                                             
NCHA Quality and Patient Safety Symposium 
Date: October 15- 16, 2018
                            Location: Friday Center, Chapel Hill,  NC 

Upcoming Virtual Learning Opportunities 

PSO Member Virtual Huddle: 
National Pt. Safety Week Activities 

Date: Tuesday February 6, 2018
Time: 2:00PM - 3:00PM

Come and share your organizations plans for this years Patient Safety Awareness Week, or hear some great ideas from others that you can implement. 
Webinar on Managing Patients Using Concentrated Insulin

Date: February 27, 2018
Time: 1:00PM - 2:00PM
Register Here
Overview: National and local patient safety event reviews reveal several challenges associated with the use of concentrated insulin during in-patient stays.  These events include use of incompatible syringe sizes, inadequate medication reconciliation practices,  availability of supplies to accommodate insulin pumps, challenges with unstable glucose levels and inconsistent use of endocrinologist and diabetes educators to support care transition between home and in-patient services. This webinar will take a closer look at the events and what is being done to prevent them.
Handoffs & Transitions of Care Webinar
Do you feel your organization has a great process for handling handoffs during patient discharges or care transfers to other hospitals, skilled nursing facilities, home health or other services? Consider being a panelist on our upcoming webinar. Contact Claudia Paren at 919-677-4134 to learn more.
                                 Date: March 8, 2018
                                 Time: 2:00-3:00pm
                                 Register Here 
Patient Safety Awareness Activity Showcase Webinar
April 5, 2018
Time: 2:00PM- 3:00PM
Register Here
2018 TQC PSO Safety Culture Fall Webinar Learning Series
September: Standardizing Safety Practices: Beyond Checklists
October: Learning Environment & Good Catches
November: Socializing Measures of Harm - NextPlane Measures Program
Call for Member Spotlight Stories!
What better way to recognize people you work with than by shining a spotlight on their hard work. Show them you value their contributions to patient safety by sharing their workplace improvement stories. 

We are seeking your help to showcase these efforts in upcoming webinars and trainings. We will work with you to make the process of sharing as easy as possible!
Speakers are asked to share a brief 10-15 minute presentation highlighting the strategies and tactics used to address:
  • National Patient Safety Awareness Week activities (April 2018 webinar)
  • Creating and sustaining a learning culture
  • Increasing event reporting
  • Recognizing or promoting good catches or near misses
  • Standardizing safety practices (i.e. handoffs, briefs, debriefs, patient safety leader walk-rounds, learning boards, etc.)
Interested or have a speaker recommendation?
Click Here to Share Your Recommendation

Additional Member Resources 

Looking for More 
TQC PSO Resources?
Visit our website.

Here you can find:
  • Information on how to keep your membership information current with our team.
  • Information about upcoming events and activities being held online and in your area. 
  • Playback links for the recording of past webinars.
  • Resources from past Safe Tables and other learning events.
  • Updates on important regulatory changes that affect patient safety within your organization.
  • Listing of other TQC PSO members you can network and collaborate with.
Questions? Contact Us!
Nancy Schanz RN, MA, MBA, MHA
Performance Improvement Specialist

Claudia Paren, RN, BSN, MSN
Performance Improvement Specialist

Laini Jarrett, BS
Project Manager, NC Quality Center

The Quality Center PSO
2400 Weston Parkway • Cary, NC 27513
Copyright © 2017 The North Carolina Quality Center, All rights reserved.

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North Carolina Hospital Association · 2400 Weston Parkway · Cary, NC 27513 · USA